35 years male with DKA

 

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment 

35 year old male farmer by occupation is brought to opd with 

C/O vomiting since 8days 

History of presenting illness:-

Patient was apparently asymptomatic one month back since then he is having occasional episodes of vomitings which are increased in frequency since past 8 days that is of 1 - 2 episodes per day,Non projectile,Non bilious,Not blood tinged,Food particles as content associated with fever,Not associated with pain abdomen

8 months back patient suffered with ? Chickenpox for 1.5 month .

2months after recovery from chicken pox he is diagnosed as having DM (probably type 1)when patient presented with unconscious state

H/o of shortness of breath( grade 2 mMRC) for 1 month which is intermittent ( increased during night),Associated with cough and fever

Burning micturation present

Cough initially Non productive later productive ,Associated with scanty sputum,Non blood tinged

Fever is low grade, intermittent,associated with night sweats not associated with chills and rigors   

Weight loss of 8 to 10 kgs from past 3 months

Progressive increase in weakness which is increased in severity since past 10days 

Decreased appetite since past 1 month 

Since 4months he was on Mixtard 10 units once daily for his DM 

But Patient stopped using these for past 1 month 

No history of palpitations, syncope , dyspnea 

No history of chest pain , wheeze

No history of urinary urgency urinary frequency or incontinence 

Past history:

N/k/c/o hypertension,asthma ,cad, tuberculosis, epilepsy

Personal history:

Mixed diet with normal appetite,Non alcoholic,Non smoker.

Family history:

No relevant family history 

Treatment history:

Treated outside for UTI - ecoli with antibiotics

Vitals - 

Blood pressure:- 140/80 mmHg right hand supine postion 

Pulse rate :-123bpm.

Respiration rate- 26cpm

Saturation- 100 on RA

Grbs - High at presentation

Temp- 100°F axillary 

Systemic examination:-

Cvs - 

on inspection chest appears to be bilaterally symmetrical elliptical shape with no scars or sinus or engorged veins

On palpation nothing felt on pulmonary area aortic, tricuspid , mitral areas 

S1S2 heard on Auscultation no murmurs to be heard

Rs- 

On inspection

Upper respiratory tract appears normal

Lower respiratory tract:

elliptical shaped chest with no supraclavicular or infra clavicular hallowing or no crowding of ribs, no scars and sinus, no engorged veins.

Trachea appears to be central

On palpation 

No rise in temperature, no tenderness

Trachea in centre

Chest expansion bilaterally symmetrical

On percussion

TVF normal 

And Percussion it's resonant

bae+ on Auscultation no added abnormal sounds to be heard

Management:

Investigations:

Started on ivf NS bolus f/b 75ml/hr 

Inj Hai 6u IV hourly---> infusion @6u/hr

2d echo - ivc 1.28cm ,collapsible

Normal chambers

Mild lvh

Hemogram:- 

Hb-7.2

TLc- 22,800

Plt- 3.3 lakhs

Microcytic hypochromic

Urea-206

Creat 4.0

Na-131

K-4.7

Cl- 95

Urine for ketones negative

Rbs- 485 mg/dl 

Hemogram:-

Hb:- 6.0

Pcv:- 19.9

TLC:-  7300

RBC:- 2.78

Platelets:-4.10

RETICULOCYTE COUNT :- 0.5

RFT :-

Blood urea:- -35

Sr creatinine:- 2.6

S.Na:- 139

S.K:- 3.7

S.Cl:- 104 

Ionized Ca:- 1.13

LFT:-

Total bilirubin:- 1.04

Direct bilirubin:- 0.23

SGPT:- 14

SGOT:-11

ALP:- 284

TOTAL PROTEIN:- 8.0

Albumin :- 2.5

A/G ration:- 0.45  

24 hour URINARY ELECTROLYTES:-

Na:- 176 

Ca :- 297 

Phosphorous:-0.87 

USG report:- 

Review USG:- 

2D echo report:- 

Upper GI endoscopy:-

Chest x ray:-

Xray kUB-

ECG:- 

CT:- 

Report

C& S blood and urine:-

DIAGNOSIS:- 

Uncontrolled sugars secondary to non compliance to medication. (Resolved )

Acute kidney injury secondary to? Pre renal secondary to ? Sepsis ?

bilateral pyelonephritis with left hydroureteronephrosis 

with anemia (microcytic hypochromic) secondary to?

GI losses 

? Iron deficiency anemia 

Treatment Given :- 

1.IVF- NS @ 75ml/hr

2.Insulin infusion @8 U/hr increase or decrease acc to GRBS(algorithm 2)

3.GRBS charting hourly and inform PG

4.Monitor Temp, PR,RR,BP hourly

5.Strict input output charting. 

6.trimethoprim + sulphamethoxazole is given for 5 days starting from 16th 

ADVICE AT DISCHARGE:- 

1.Inj.HAI sc/tid 

(8am ---1pm---8am)

(14u----14u-----14u)

2.Inj.NPH sc/bd 

  (8am----8pm)

  (10u------10u) 

3. Trimethoprim (160mg)+ sulphamethoxazole (800mg) po/od for 2 days (day 6,7)

4.Tab Orofer XT po/bd 

5.strict diabetic diet . 

GRBS CHARTING:- 

18/4/23 

2am --148 

8am---116 

2pm---112 --12 hai 

4pm---391 

8pm----395--16u hai-10 nph 

19/4/23 

2am---161 

8am---124--14u hai +10 u nph 

1pm--108---14u hai 

8pm---92 ---10u hai+6u nph 

20/4/23 

2am---141 

8am---147---14u hai+10 nph